NACE Basic Care and Comfort 2 — Questions and Answers
Question 1: A nurse is assisting a patient with dysphagia. Which dietary modification is most appropriate to reduce the risk of aspiration?
- Clear liquid diet
- Thickened liquids (Correct answer)
- Regular diet with small bites
- NPO status until further evaluation
Correct answer: Thickened liquids
Thickened liquids slow the flow of liquid, giving the patient more time to control swallowing and reducing aspiration risk in patients with dysphagia.
Dysphagia affects up to 22% of adults over 50. The International Dysphagia Diet Standardisation Initiative (IDDSI) classifies liquid thickness from thin (Level 0) to extremely thick (Level 4). Thickened liquids reduce flow rate, allowing more time for airway protection during swallowing. Clear liquids are the most aspirated consistency due to their fast flow rate.
Question 2: When repositioning a patient to prevent pressure injuries, how frequently should the nurse turn the patient?
- Every 4 hours
- Every 2 hours (Correct answer)
- Every 8 hours
- Only when the patient requests
Correct answer: Every 2 hours
Evidence-based guidelines recommend repositioning patients at least every 2 hours to redistribute pressure and prevent tissue breakdown.
The National Pressure Injury Advisory Panel (NPIAP) recommends repositioning immobile patients at least every 2 hours. Prolonged pressure causes tissue ischemia; capillary closing pressure is approximately 32 mmHg, and sustained pressure above this threshold leads to cellular death.
Question 3: A patient reports pain at a level of 7 on a 0-10 scale following surgery. Which non-pharmacological intervention can the nurse implement independently?
- Increase the IV opioid drip rate
- Apply a warm compress to the surgical site
- Administer a PRN analgesic
- Apply guided imagery and relaxation techniques (Correct answer)
Correct answer: Apply guided imagery and relaxation techniques
Guided imagery and relaxation techniques are independent nursing interventions that can complement pharmacological pain management without requiring a physician order.
Non-pharmacological pain management techniques within the nurse's independent scope of practice include guided imagery, progressive muscle relaxation, deep breathing exercises, music therapy, massage, distraction, and positioning. These interventions activate the gate control theory of pain by sending competing sensory signals.
Question 4: Which position is most appropriate for a patient experiencing difficulty breathing?
- Supine with legs elevated
- High Fowler's position (Correct answer)
- Prone position
- Left lateral recumbent
Correct answer: High Fowler's position
High Fowler's position (60-90 degrees) promotes maximum lung expansion by allowing the diaphragm to descend fully, reducing the work of breathing.
High Fowler's position elevates the head of the bed 60-90 degrees, allowing gravity to pull the diaphragm downward and increasing thoracic cavity volume. This position reduces venous return to the heart and lungs, decreasing pulmonary congestion. It is the preferred position for patients with dyspnea, COPD, CHF, and during meals for patients at aspiration risk.
Question 5: A nurse is performing oral care for an unconscious patient. What is the priority safety measure?
- Using a soft-bristle toothbrush
- Positioning the patient on their side (Correct answer)
- Applying lip moisturizer afterward
- Using fluoride-free toothpaste
Correct answer: Positioning the patient on their side
Positioning an unconscious patient on their side (lateral position) prevents aspiration of oral secretions and cleaning solutions during mouth care.
Unconscious patients lack protective reflexes including the cough and gag reflexes, making aspiration a critical risk during oral care. Lateral positioning allows fluids to drain from the mouth by gravity rather than pooling in the posterior pharynx.
Question 6: What is the recommended daily fluid intake for an average healthy adult?
- 500-1000 mL
- 1500-2000 mL
- 2500-3000 mL (Correct answer)
- 3500-4000 mL
Correct answer: 2500-3000 mL
The general recommendation for healthy adults is approximately 2500-3000 mL of fluid daily, though individual needs vary based on activity level, climate, and health status.
The National Academies of Sciences recommends approximately 3,700 mL/day for men and 2,700 mL/day for women from all beverages and food combined. About 20% of daily fluid intake comes from food. Fluid needs increase with fever, exercise, hot climate, and certain medications.
NACE Basic Care and Comfort 2
A nurse is assisting a patient with dysphagia.
Which dietary modification is most appropriate to reduce the risk of aspiration?